We Have to Dream Big

There are so many things to distract us from our big dreams. We face a daily deluge of emails. We need to finish our notes. We have to prepare our next seminar for the clerkship. But we are in a time of transformative change in health care and medical education. If we do not dream the big dreams, we will miss the opportunity to influence our future. As your next president, I hope to help us dream the dreams that are big enough.

In this introductory president’s column, I want to share with you two dreams of where we as an organization will head over the next year and beyond. These dreams are influenced by three formative experiences in my life. I came to this country as an immigrant, speaking no English and not understanding much of US culture. My experience coming from a wealthy European country was different from the immigrant experience of many, but it still gave me a sense of what it is like to be an outsider. As a medical student, I worked with Chilean medical students and witnessed their courageous fight for social justice and political freedom under the brutal regime of Augusto Pinochet. And in 2013, my niece, Sophie Steiner, while dying of cancer, movingly thought of others more than herself. She advocated for increased support of adolescent patients who unlike her had few family resources. Today the Be Loud Sophie Foundation (https://beloudsophie.org) provides such support to young cancer patients, helping them to stay true to themselves in the face of overwhelming illness.

But these dreams have to be more than my dreams. They have to be our dreams. As a group of talented family medicine educators we are powerful enough to make important progress in achieving two dreams that align with the core values of the Society of Teachers of Family Medicine, especially diversity, integrity, excellence, and relationships (http://www.stfm.org/About).

We need to realize the dream of achieving a workforce where 25% of students are choosing careers in family medicine by 2030 because it will improve the health of our nation. It is an ambitious goal that has been endorsed by the national organizations of family medicine.¹ Many solutions are needed to solve the wicked problem of physician shortage. Payment reform is certainly one of those solutions. But there are solutions more under our control as educators. We need to create an environment where family physicians in the best practices are competing with one another to model what it means to be a family medicine physician. We will examine using the term “adjunct faculty” or “community preceptor.” We could just call them teachers of family medicine and set rigorous criteria to be selected to teach our students. STFM will offer the faculty development tools for practices to meet those criteria. We have made significant recent progress in creating such an environment.

Established in the summer of 2015, the STFM-led Preceptor Expansion Initiative (http://www.stfm.org/Resources/ResourcesforMedicalSchools/PreceptorExpansionInitiative) has directly contributed to major breakthroughs to improve our ability to recruit, and to retain high quality practices to teach our students. The Centers for Medicare and Medicaid Services (CMS) recently announced that student documentation could again be used by teaching physicians. Redocumentation by the teaching physician is no longer needed. A recent survey estimated that this will save 2 hours per day for physicians who work with a student (M. Theobald, personal communication, January 2018). STFM helped bring about this change by shining the spotlight on this issue over years. STFM used its connections with other partners such as the American Association of Medical Colleges and the American Association of Physician Assistants to deliver aligned messages to CMS. And finally, STFM used government relations, mainly through Hope Wittenberg, MA, to understand that the timing was right to deliver the message. The second recent breakthrough came when STFM worked closely with the American Board of Family Medicine to create a seamless path for family physicians who teach students to receive practice improvement credit (formerly MOC4). We still have a long way to go, but we have recently made impressive progress because we are passionate, committed, and work well as a group.

We also need to work harder toward realizing the dream of improving health equity in our country. Undoubtedly this is even more of a wicked problem than the workforce issue and we are not nearly as far along as we should be. It is a problem that extends well beyond the borders of medicine. Health care probably contributes as little as 10% to health outcomes.² Other factors play a much larger role. We need our public health colleagues, our policy makers, our business partners, and many others to work with us to influence the social determinants of health such as food, housing stability, and economic security. But there are things that we as educators in family medicine can directly influence. I will highlight two examples.

Evelyn Figueroa, MD, is a family physician and educator at the University of Illinois in Chicago. She has created a food pantry inside a clinic that is open daily. The pantry is providing needed food to patients. Evelyn’s work with community partners is raising awareness of this important issue in the business community. She is powerfully teaching her learners about food insecurity in a real life setting and inspiring her learners to make a difference.

Suzanne Barakat, MD, provides another compelling example. She recently graduated from the family medicine residency program at the University of California, San Francisco, and was the plenary speaker at the 2018 STFM Annual Spring Conference. With courage and passion, she is speaking out against hate and intolerance. Through her actions, she is giving us as teachers the language and the inspiration needed to speak up when we witness hate and intolerance. She called on us to pass these lessons to our learners.

These are two powerful examples we can learn from, but there are many more. Some are already well developed but not well publicized, some are in early stages and need support, and some are still in someone’s imagination and need help with implementation. I believe that STFM can identify, support, and disseminate such local projects, and thus improve health equity across our country in many small but important steps.

These are two of my dreams that align with STFM’s core values. Are these the right dreams? Are they big enough? Let me know.